[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Name of Medical Facility] [Address of Medical Facility] [City, State, ZIP Code] Attention: Medical Records Department Subject: Request for Medical Records Dear Sir/Madam, I hope this letter finds you well. I am writing to formally request copies of my medical records, pertaining to my treatment at your esteemed medical facility. I believe it is essential to have a comprehensive understanding of my medical history as I continue to seek appropriate healthcare. Furthermore, I have provided the necessary information below to facilitate the retrieval of my medical records: 1. Full Name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Address: [Your Current Address] 4. Social Security Number: [Your Social Security Number] 5. Medical Record Number (if applicable): [Your Medical Record Number, if known] Please include the following information in the copies of my medical records: 1. Consultation notes from all healthcare providers 2. Diagnostic reports, including laboratory results, X-rays, MRI scans, etc. 3. Surgical reports, if any 4. Prescription and medication history 5. Immunization records 6. Treatment plans and progress notes 7. Any other relevant medical documentation I request that you provide the copies of my medical records in an electronic format, preferably by email or a secure online platform. If electronic delivery is not available, please inform me of the alternative options. If there are any fees associated with retrieving or providing copies of my medical records, please inform me in advance. I am willing to cover reasonable costs as permitted by Connecticut state law. I would appreciate receiving my medical records within the shortest time frame possible, preferably within 30 days of receiving this letter. If you foresee any delays, kindly inform me of the reasons for such delays and provide an estimated timeline for when I can expect to receive the requested medical records. Should you require any additional information or if there are any questions regarding my request, please do not hesitate to contact me at the phone number or email address provided above. Thank you for your attention to this matter. I expect a prompt response and your cooperation in ensuring that I can access the medical records in a timely manner. Sincerely, [Your Name]
Connecticut Sample Letter for Request for Medical Records
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How to fill out Connecticut Sample Letter For Request For Medical Records?
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Unless specified otherwise herein, all parts of a medical record shall be retained for a period of seven (7) years from the last date of treatment, or, upon the death of the patient, for three (3) years.
If the patient wrote a personal letter requesting records, make sure the following patient information was in the original request:Date of birth.Name.Social Security number.Contact information (address and phone number)Email address.Dates of service and specific records requested (tests, discharge notes, etc.)More items...
The subject line of your request should be "FOIL Request". Please inform me of the cost of providing paper copies of the following records include as much detail about the records as possible, including relevant dates, names, descriptions, etc..
What information should be included in a patient's medical records?The initial health history and physical examination from the doctor.Consultation reports from specialists, as well as any notes.Operative reports / Medical procedure reports.More items...?
I was treated in your office at your facility between fill in dates. I request copies of the following or all health records related to my treatment. Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.
Most practices or facilities will ask you to fill out a form to request your medical records. This request form can usually be collected at the office or delivered by fax, postal service, or email. If the office doesn't have a form, you can write a letter to make your request.
No provider shall charge more than sixty-five cents per page and the cost of first class postage, if applicable, for furnishing a health record pursuant to this subsection, except such provider may charge a patient the amount necessary to cover the cost of materials for furnishing a copy of an x-ray, provided no such
According to a Trustwave report, a healthcare data record may be valued at up to $250 per record on the black market, compared to $5.40 for the next highest value record (a payment card).
If the patient wrote a personal letter requesting records, make sure the following patient information was in the original request:Date of birth.Name.Social Security number.Contact information (address and phone number)Email address.Dates of service and specific records requested (tests, discharge notes, etc.)More items...
